Jun-11
How Effective Are Precautionary Measures For MRSA In Hospitals?
By Brian McCurdy, Senior Editor
A recent study in the New England Journal of Medicine (NEJM) shows good results from the precautionary measures instituted in Veterans Affairs (VA) hospitals in 2007 to prevent the spread of methicillin resistant Staphylococcus aureus (MRSA). However, a second NEJM study suggests MRSA precautions are not effective in intensive care units (ICU).
Michael Cohen, DPM, notes that at the VA, the “MRSA bundle” includes hand washing in and out of the inpatient and clinic rooms; wearing gowns prior to entering the rooms of MRSA colonized or infected patients; nasal screening of all admitted patients; and proper catheter insertion. He notes patients also undergo vancomycin prophylaxis before surgery with large implants and have the use of a surgical scrub brush the night before surgery. In addition, he says there is 48 hours of surgical implant isolation before surgery and frequent culturing of ventilators, dental and dialysis lines.
The first NEJM study notes that between the implementation of the MRSA bundle in October 2007 and June 2010, the percentage of patients who were screened for MRSA at hospital admission increased from 82 to 96 percent at 153 VA facilities. Study authors note the screening of patients at transfer or discharge increased from 72 to 93 percent during the same period. The mean prevalence of MRSA colonization or infection at the time of hospital admission was 13.6 percent, according to the first study.
Researchers say the rates of healthcare-associated MRSA infections in intensive care units at VA facilities declined by 62 percent with implementation of the bundle, from 1.64 infections per 1,000 patient-days in October 2007 to 0.62 per 1,000 patient-days in June 2010. In the same period, the study says the rates of healthcare–associated MRSA infections in non-intensive care units fell by 45 percent, from 0.47 per 1,000 patient-days to 0.26 per 1,000 patient-days.
However, a second study in the NEJM notes that surveillance and expanded use of barrier precautions for MRSA and vancomycin resistant Enterococcus (VRE) were not effective in the ICU.
The study involved 5,434 patients admitted to 10 intervention ICUs and 3,705 patients admitted to eight control ICUs. Researchers obtained surveillance cultures from all ICU patients, according to the study. For the intervention ICUs, the care of patients colonized with MRSA or VRE required contact precautions including clean gloves, gowns and hand hygiene after contacts. Researchers noted that all other patients received care with universal gloving until discharge or confirmation of negative surveillance cultures. For the patients at intervention ICUs, healthcare employees used gloves for 82 percent of patients, gowns for 74 percent and hand hygiene for 69 percent.
The second study notes that when adjusting for baseline incidence, the mean ICU-level incidence of colonization or infection with MRSA or VRE per 1,000 patient-days at risk did not differ significantly between the intervention and control ICUs. The researchers note this may be due to prolonged turnaround time on surveillance cultures, and less than required adherence to contact precautions and universal gloving.
A Closer Look At MRSA Precautions In The VA
Both Dr. Cohen and Howard Kimmel, DPM, have seen a decrease in hospital acquired MRSA infections in their VA facilities. Dr. Cohen notes the protocol has also reduced the rates of VRE and C. difficile infection, which he adds has made active surveillance cost effective.
Dr. Kimmel says his VA staff makes a notation of any positive nares swab of MRSA and the infection control committee evaluates patients who are admitted for any type of infection. He says this process aids with empiric antibiotic therapy when treating any type of infections.
The most effective aspect of the MRSA bundle is hand hygiene, according to Dr. Kimmel, the Director of Residency Training at the Louis Stokes Cleveland Veterans Affairs Medical Center in Cleveland. His facility has signs and appropriate antimicrobial agents at each patient room. In addition, he notes the post-anesthesia care unit and surgical ICU have a person who monitors and reports to infection control that all healthcare providers are following the appropriate protocol.
The MRSA bundle works because it approaches the problem from several different angles, according to Dr. Cohen, the Chief of the Podiatric Section Surgical Service at the Miami Veterans Affairs Medical Center. He would add the requirement that physicians stop wearing neckties as ties can harbor an extensive amount of pathogens and may play a role in transmitting MRSA.
“The most challenging part of the bundle involves a strict change in the culture or mindset. Simply put, old habits are hard to break,” says Dr. Cohen.
Study Compares TCCs And RCWs For Offloading Effectiveness
By Brian McCurdy, Senior Editor
Offloading is critical for patients with diabetic foot ulcers but do total contact casts (TCCs) or removable cast walkers (RCWs) provide more effective offloading?
A new study in Clinical Biomechanics compared TCC with RCW boots in regard to plantar loading during barefoot walking. The study consisted of 23 patients with diabetes, 11 of whom wore a TCC and 12 of whom wore a RCW. Researchers conducted plantar loading assessments with patients walking barefoot and with the patients wearing the offloading devices.
The study notes no difference in offloading between TCCs and RCW boots. Patients in RCW boots had greater reductions in forefoot peak pressure, pressure-time integral, maximum force and force-time integral in comparison to barefoot walking, according to the study. The authors also note that healing times were similar in both groups although patients in TCCs experienced more healed ulcers in comparison to those in RCWs. The study concludes that despite the superior forefoot offloading afforded by RCWs, the fact that the boots are less effective at healing ulcers suggests the important role of patient adherence in ulcer healing.
Jason Hanft, DPM, FACFAS, has had over 20 years experience with both TCCs and RCWs. At the American College of Foot and Ankle Surgeons Annual Scientific Conference in 1993, he presented data on over 1,300 consecutive diabetic foot ulcers treated with TCCs, RCWs and healing sandals. He found “significantly more rapid healing” for patients in the TCC, noting an average of approximately 4.8 weeks for complete wound closure for the TCC in comparison to slightly over six weeks for the RCW and nearly 10 weeks for patients in sandals.
Dr. Hanft believes the new study results show the RCW to have greater forefoot offloading because of the type of foot bed used on the TCC. As he notes, the cast style boot forces the TCC to rock forward and carry most of the patient’s weight on the forefoot, which increases pressure. He says a walking peg or rubber plug on the walking surface of the cast will eliminate nearly all forefoot pressure and cause a “peg leg” style gait.
“RCWs are excellent tools but variables in style, footbed and sole configuration make it important to select the right one for the individual needs of the patient and wound location,” says Dr. Hanft, the Director of Podiatric Medical Education at Baptist Health in South Florida.
The advantages of the TCC include excellent pressure reduction, “fantastic” reduction in strain rate, a controlled environment and greater patient adherence, according to Dr. Hanft. He notes disadvantages include the time-consuming application, the level of skill required to apply the cast and the inability for the DPM to assess the wound between clinic visits.
As for the RCW, Dr. Hanft cites advantages including ease of application, wound healing ability, lower pressure and strain rate, and the ability to change dressings and inspect the wound at any time. Disadvantages include the fact that the boots are removable and have incomplete contact, which he says makes the outcome patient dependent.
What An Online Poll Reveals About Corticosteroids For Plantar Heel Pain
A recent Podiatry Today online poll shows a range of opinions on whether one should give patients a corticosteroid injection on the first visit for plantar heel pain (see https://bit.ly/hPuvEg ).
Of the 591 people who responded, 20 percent never give corticosteroid injections on the first visit while 28 percent give initial injections to at least half of patients.
“Of all the treatments that I do for plantar fasciitis, nothing works as well as cortisone injections,” notes William Fishco, DPM. He estimates nearly 100 percent of his patients get a cortisone injection unless they have an allergy.
At the initial visit of a patient having plantar fasciitis, Dr. Fishco will offer either a cortisone injection or nonsteroidal anti-inflammatory drug (NSAID). He also starts the patient on a stretching and icing protocol. Patients should wear supportive shoes and avoid going barefoot and wearing sandals, slippers or flimsy shoes, according to Dr. Fishco, who is a faculty member of the Podiatry Institute and in private practice in Phoenix.
At a four-week follow-up visit, if the pain has not resolved, Dr. Fishco will administer another cortisone injection and perform a series of three injections four weeks apart if necessary. He uses 40 mg of triamcinolone acetate (Kenalog, Bristol-Myers Squibb) for the cortisone injection.
In his posted comments on the online poll, Lowell Scott Weil Sr., DPM, FACFAS, describes the “Weil Group” clinical guidelines for a patient’s first visit with a history of three months or less of plantar fasciitis with no prior treatment. His guidelines call for eccentric Achilles stretching, soaking the heel in ice water for 10 minutes, NSAIDs, avoidance of flat shoes and an OTC insert.
“One of our studies shows that with this program, 75 percent of patients feel better within six weeks. If not, a cortisone shot and other modalities are recommended,” says Dr. Weil, the Medical Director of the Weil Foot and Ankle Institute in Des Plaines, Ill.
Furthermore, Dr. Weil notes for an active person with a close to normal body mass index whose pain level is 8 on a scale of 1 to 10 and has to travel in the next couple of weeks, he offers a cortisone shot on the first visit. He estimates he offers corticosteroids on the initial visit 10 percent of the time.
However, Robert Kornfeld, DPM, suggests avoiding using fibrolytic medicines in an area of ligamentous inflammation.
“There are many ways that we can heal inflammation by provoking a primary inflammatory response instead of suppressing chronic pathways of inflammation,” says Dr. Kornfeld, the Director of Holistic and Complementary Podiatric Medicine in New York City and Manhasset, N.Y. “Since it is primary inflammation that repairs our cells, this is what we need to key in on.”
In Brief
The Barry University School of Podiatric Medicine announces that Margaret Elizabeth Brand, MD, accepted an honorary Doctor of Science degree during the school’s podiatric medicine graduation. Dr. Brand, 91, also accepted a posthumous honorary Doctor of Science degree on behalf of her late husband, Paul Wilson Brand, MD.
The university honored the Brands by officially naming Barry’s first research hub as the Paul & Margaret Brand Research Center.
